In Nigeria, Overcoming COVID-19 Requires Tackling Epidemiological Challenges and Population Density
After much anticipation, the first COVID-19 vaccines are being rolled out worldwide. However, high-income countries have secured most of the supply for themselves, while many low- and middle-income countries are reliant on an initiative called COVAX. Though the first COVAX supplies have arrived, they are only expected to cover 20% of the population in most countries by the end of 2021. As a result, parts of Africa, South America and Asia will likely not be fully vaccinated from the coronavirus until 2023. With new variants of the virus circulating at the same time, the pandemic is expected to remain a persistent threat in sub-Saharan Africa.
One of the countries experiencing a new variant, Nigeria, finally received their first shipment of the COVAX supply. While this is a much-needed boost, not all Nigerian states will see immediate relief, as those with inadequate security around their cold storage facilities will not receive doses until they meet security requirements. Thankfully, private companies have volunteered to support the acquisition and rollout of the vaccine to speed the process along. The Coalition Against COVID-19, led by top business executives, plans to purchase the “42M doses allocated to Nigeria by the African Union’s vaccine procurement program.” In addition, Zipline, a company that manufactures drones, has partnered with the Kaduna state to deliver vaccines with their drones “without significant state investment in cold-chain storage.”
While priority groups get vaccinated over time, Nigeria can mitigate the spread of the pandemic by identifying which regions are most vulnerable to the health impact of COVID-19, which can be done using hyper-local, granular tools such as our Africa COVID-19 Community Vulnerability Index. The Africa CCVI is a powerful tool for precision policy-making within public health that helps leaders determine where to focus limited resources and which interventions to implement to make an impact, depending on each community’s specific needs. Policymakers can implement responses tailored toward their most at-risk populations, such as food-aid for fragile areas or scale-up healthcare infrastructure in regions with higher older (over 60) populations.
In this article, we assessed the drivers of deaths in Nigeria to determine which factors of vulnerability are important to consider in the response.
Epidemiological Factors, Population Density have Driven Deaths so Far
As of March 29, 2021, Nigeria has reported 162,593 COVID-19 cases and 2,048 deaths among a national population of 209M individuals, according to the Nigeria Center for Disease Control. However, not every state has been affected equally.
To better understand the drivers behind the distribution of the COVID-19 burden among Nigeria’s states, we compared deaths per 100K for each Nigerian state reported by Humanitarian Emergency Response Africa (HERA) to our Africa COVID-19 Community Vulnerability Index scores for each state. Our analysis revealed that states with higher scores in the themes of Epidemiological and Population Density Vulnerability suffered a greater number of deaths per 100K individuals.
Figure 1 displays the relationship between cumulative COVID-19 deaths per 100K and Africa CCVI Epidemiological Vulnerability (non-communicable diseases, HIV prevalence, infectious diseases prevalence, smoking, and BCG vaccination). States with greater disease prevalence experience more deaths, most likely due to the increased severity of COVID-19 infection caused by additional comorbidities.
Figure 1: HERA total deaths per 100K versus Epidemiological Vulnerability by March 17, 2021. Point sizes reflect population size and colors reflect vulnerability. Line represents Loess smoothing with a 95% confidence interval.
Edo, the state in the highest quintile of Epidemiological Vulnerability, has experienced the greatest number of COVID-19 deaths per 100K. Now, as the second wave of the pandemic hits, the state is suffering from an additional wave of Lassa Fever. Among the 14 states where Lassa was reported so far in 2021, Edo faces one of the greatest burdens, with 97 cases and 11 deaths as of March 29. This will unfortunately pose further challenges for the state, as they must now devote resources to combat both a global pandemic and a fever with an overall fatality rate of about 20% so far.
While high disease prevalence alone can worsen the COVID-19 burden, high population density further complicates the situation, as it increases disease transmission of all types. Figure 2 reveals the relationship between Population Density Vulnerability and weekly deaths per 100K. As the Population Vulnerability score increases, so does the average number of weekly reported deaths, as the risk for transmission due to population density grows.
Figure 2: Population-Weighted Average Weekly Deaths per 100K by March 25, 2021, with states grouped by Population Density.
The Nigerian states that have the highest Population Density scores are Abia, Akwa Ibom, Anambra, Federal Capital Territory (FCT), Imo, Kano, Lagos, and Rivers (Fig 3). In addition to its very high Population Density Vulnerability, concerningly, FCT also ranks in the highest quintile for Epidemiological Vulnerability.
Figure 3: Subnational Population Density Vulnerability, viewable on the Africa CCVI website.
Addressing Population Density Vulnerability By Tracking Mobility
According to Google’s Mobility Reports, citizens in the Federal Capital Territory have increased their visits to workplaces, groceries and pharmacies, and retail stores and recreational facilities over the past couple of months, in some cases more frequently than before the pandemic began (Fig. 4). This trend follows a 5-week closure of all bars, nightclubs, and restaurants, among other restrictions, across the country, issued in December 2020. The subsequent increase in movement can lead to an increase in COVID-19 transmission amid a region already subject to additional disease prevalence. As a result, regions highly vulnerable with respect to both epidemiology and population density, such as FCT, require a response to the pandemic that targets their multiple pain points, such as implementing mandatory mask-wearing and social distancing in addition to promoting hand-washing and vaccination.
Figure 4: Percent Change in Mobility from pre-Pandemic Baseline by Category in Federal Capital Territory. The mobility reduction during the lockdown was short lived.
Lack of Testing Likely Makes These Estimates Worse
We would be remiss if we did not address the important caveat to these findings: Due to the notable lack of COVID-19 testing in Nigeria, reported cases and deaths are most likely far lower than the true number of infections and deaths across the country. While African countries such as South Africa and Morocco have performed more than 145 tests per 1000, Nigeria has only conducted 8.4 per 1000, according to Our World in Data (Fig. 5). It currently takes South Africa only 2.5 weeks to test as much as Nigeria has across the entire pandemic (and it takes the U.S. only 2 days). Considering the information we do have access to, we must acknowledge that our perception of the burden of the pandemic in Nigeria is an underestimation.
To more accurately determine the spread of COVID-19 in the first wave, the NCDC, the Nigerian Institute for Medical Research (NIMR), and their partners conducted a household seroprevalence study in September and October 2020 across the states of Lagos, Enugu, Nasarawa, and Gombe. The surveys revealed an antibody prevalence of 23% in Lagos and Enugu, 19% in Nasarawa, and 9% in Gombe, which suggest far higher rates of COVID-19 infection than those reported through national surveillance. This disparity between reported and actual data holds us back from grasping the full extent of the pandemic.
Figure 5: Our World in Data Cumulative COVID-19 tests per 1,000 people by March 26, 2021.
We Must Act Now
Establishing a baseline of policies to counteract the pandemic is especially important right now in Nigeria, as the NCDC recently announced a new variant in the country, separate from those of South Africa and the United Kingdom, that has already begun to impact the healthcare system, as individuals unknowingly bring the variant to hospitals. Scientists have yet to fully understand the nature of this new variant, so policy-makers must be vigilant in getting ahead of the new strain before it yields consequences similar to those in South Africa.
Therefore, knowing that Epidemiological and Population Density Vulnerability have been associated with higher COVID-19 deaths in Nigeria, policy makers could consider concurrently promoting non-COVID-19 disease surveillance and vaccinations (Fig. 6) and increasing the stringency of mask-wearing and social distancing measures during this time, to target these two risk factors. On top of that, the country could allocate more resources towards testing. With an increase in testing, it can better understand the new variant and identify the vulnerabilities that influence its distribution of deaths.
In addition to targeting these two vulnerabilities, regional policymakers can take additional long-term measures to curb the spread of the virus in the future while the vaccine rollout gets started. These actions include: instituting lockdowns and shielding policies where the virus is prominent, tracking mobility data to see how citizens are responding, addressing any vulnerabilities (such as socioeconomic challenges) that co-occur, and designing social protection measures if needed.
The arrival of the COVID-19 vaccine will bring about much-needed relief in Nigeria. However, government officials and organizations will continue to remain vigilant towards the virus by promoting additional measures to protect its vulnerable populations. The Africa CCVI combined with surveillance data can help stakeholders understand who is vulnerable and why, to design interventions to help them weather future impacts from COVID-19.
Surgo Ventures contributors to this article include: Daniela Garcia, Bettina Hammer, Rahul Joseph, Anubhuti Mishra, and Valerie Valerio.